White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Newborn Screen 2

Facility

$138.00

Service Code	CPT 99001
Hospital Charge Code	4201300
Hospital Revenue Code	300
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$89.70
Rate for Payer: Aetna Commercial	$75.90
Rate for Payer: Amerigroup CHIP/Medicaid	$12.42
Rate for Payer: BCBS of TX Blue Advantage	$10.11
Rate for Payer: BCBS of TX Blue Essentials	$12.14
Rate for Payer: BCBS of TX PPO	$13.55
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cigna Medicaid	$13.07
Rate for Payer: Molina CHIP/Medicaid	$13.07
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$13.07
Rate for Payer: Scott and White EPO/PPO	$69.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.07
Rate for Payer: Superior Health Plan EPO	$18.77

Newborn Screen SO

Facility

$138.00

Service Code	CPT 99001
Hospital Charge Code	4201300
Hospital Revenue Code	300
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$89.70
Rate for Payer: Aetna Commercial	$75.90
Rate for Payer: Amerigroup CHIP/Medicaid	$12.42
Rate for Payer: BCBS of TX Blue Advantage	$10.11
Rate for Payer: BCBS of TX Blue Essentials	$12.14
Rate for Payer: BCBS of TX PPO	$13.55
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cigna Medicaid	$13.07
Rate for Payer: Molina CHIP/Medicaid	$13.07
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$13.07
Rate for Payer: Scott and White EPO/PPO	$69.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.07
Rate for Payer: Superior Health Plan EPO	$18.77

New PT Wound Visit Level II

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	7150451
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$149.60
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$37.80
Rate for Payer: Molina CHIP/Medicaid	$37.80
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$37.80
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.80

New PT Wound Visit Level III

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	7150469
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$267.15
Rate for Payer: Aetna Commercial	$226.05
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$134.82
Rate for Payer: BCBS of TX Blue Essentials	$161.16
Rate for Payer: BCBS of TX PPO	$179.75
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cigna Medicaid	$51.08
Rate for Payer: Molina CHIP/Medicaid	$51.08
Rate for Payer: Multiplan Auto	$267.15
Rate for Payer: Multiplan Commercial	$267.15
Rate for Payer: Multiplan Workers Comp	$267.15
Rate for Payer: Parkland Medicaid	$51.08
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.08

New PT Wound Visit Level IV

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	7150477
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$317.20
Rate for Payer: Aetna Commercial	$268.40
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$228.25
Rate for Payer: BCBS of TX Blue Essentials	$272.85
Rate for Payer: BCBS of TX PPO	$304.34
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cigna Medicaid	$74.74
Rate for Payer: Molina CHIP/Medicaid	$74.74
Rate for Payer: Multiplan Auto	$317.20
Rate for Payer: Multiplan Commercial	$317.20
Rate for Payer: Multiplan Workers Comp	$317.20
Rate for Payer: Parkland Medicaid	$74.74
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.74

New PT Wound Visit Level V

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	7150485
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$397.16
Rate for Payer: Aetna Commercial	$327.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$297.87
Rate for Payer: BCBS of TX Blue Essentials	$356.08
Rate for Payer: BCBS of TX PPO	$397.16
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cigna Medicaid	$92.92
Rate for Payer: Molina CHIP/Medicaid	$92.92
Rate for Payer: Multiplan Auto	$387.40
Rate for Payer: Multiplan Commercial	$387.40
Rate for Payer: Multiplan Workers Comp	$387.40
Rate for Payer: Parkland Medicaid	$92.92
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.92

N GONORRHOEAE DNA AMP PROBE

Facility

$245.00

Service Code	CPT 87591
Hospital Charge Code	1709179
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$159.25
Rate for Payer: Aetna Commercial	$36.84
Rate for Payer: Aetna Medicare	$52.64
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$77.55
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cigna Medicaid	$35.09
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$35.09
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$159.25
Rate for Payer: Multiplan Commercial	$159.25
Rate for Payer: Multiplan Workers Comp	$159.25
Rate for Payer: Parkland Medicaid	$35.09
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.09
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

niCARdipine 2.5 mg/mL Inj Soln 10 mL

Facility

$466.00

Service Code	HCPCS J2404
Hospital Charge Code	77724665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$302.90
Rate for Payer: Amerigroup CHIP/Medicaid	$41.94
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.17
Rate for Payer: BCBS of TX PPO	$0.19
Rate for Payer: Cash Price	$316.88
Rate for Payer: Cash Price	$316.88
Rate for Payer: Multiplan Auto	$302.90
Rate for Payer: Multiplan Commercial	$302.90
Rate for Payer: Multiplan Workers Comp	$302.90
Rate for Payer: Scott and White EPO/PPO	$233.00
Rate for Payer: Superior Health Plan EPO	$63.38

niCARdipine 2.5 mg/mL Inj Soln 10 mL

Facility

$466.00

Service Code	HCPCS J2404
Hospital Charge Code	77724665
Hospital Revenue Code	636
Min. Negotiated Rate	$116.50
Max. Negotiated Rate	$233.00
Rate for Payer: Cash Price	$316.88
Rate for Payer: Cigna Commercial	$116.50
Rate for Payer: Scott and White EPO/PPO	$233.00

nicotine 14 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78424116
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nicotine 14 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78424116
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

nicotine 21 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78430226
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nicotine 21 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78430226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

nicotine 7 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78414941
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nicotine 7 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78414941
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

NIFEdipine 10 mg Cap

Facility

$14.00

Service Code	HCPCS J8499
Hospital Charge Code	77725772
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$7.00
Rate for Payer: Cash Price	$9.52
Rate for Payer: Cigna Commercial	$3.50
Rate for Payer: Scott and White EPO/PPO	$7.00

NIFEdipine 10 mg Cap

Facility

$14.00

Service Code	HCPCS J8499
Hospital Charge Code	77725772
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$9.10
Rate for Payer: Amerigroup CHIP/Medicaid	$1.26
Rate for Payer: BCBS of TX Blue Advantage	$4.20
Rate for Payer: BCBS of TX Blue Essentials	$5.04
Rate for Payer: BCBS of TX PPO	$5.60
Rate for Payer: Cash Price	$9.52
Rate for Payer: Multiplan Auto	$9.10
Rate for Payer: Multiplan Commercial	$9.10
Rate for Payer: Multiplan Workers Comp	$9.10
Rate for Payer: Scott and White EPO/PPO	$7.00
Rate for Payer: Superior Health Plan EPO	$1.90

NIFEdipine 30 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725876
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

NIFEdipine 30 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725876
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

NIFEdipine 60 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725927
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

NIFEdipine 60 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725927
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

NIPPLE SHIELD

Facility

$18.48

Hospital Charge Code	111289
Hospital Revenue Code	270
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$12.01
Rate for Payer: Aetna Commercial	$10.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1.66
Rate for Payer: BCBS of TX Blue Advantage	$5.54
Rate for Payer: BCBS of TX Blue Essentials	$6.65
Rate for Payer: BCBS of TX PPO	$7.39
Rate for Payer: Cash Price	$16.26
Rate for Payer: Multiplan Auto	$12.01
Rate for Payer: Multiplan Commercial	$12.01
Rate for Payer: Multiplan Workers Comp	$12.01
Rate for Payer: Scott and White EPO/PPO	$9.24
Rate for Payer: Superior Health Plan EPO	$2.51

NIPPLE SHIELD

Facility

$18.48

Hospital Charge Code	111289
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.26

nitrofurantoin macrocrystals-monohydrate 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77727165
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

nitrofurantoin macrocrystals-monohydrate 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77727165
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges